Eligibility Criteria of Participants in Randomized Controlled Trials Assessing Conservative Management of Cervical Radiculopathy: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: The aim of this study was to evaluate the inclusion and exclusion criteria for participants in randomized control trials (RCTs) assessing conservative management for cervical radiculopathy (CR), to determine if any consensus exists within the literature. SUMMARY OF BACKGROUND DATA: A 2012 systematic review identified a lack of uniformity for the eligibility criteria of participants in RCTs evaluating conservative interventions for CR. Since then, a large number of RCTs have been published, signaling the need for an updated evaluation of this topic. MATERIALS AND METHODS: We electronically searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022, to identify RCTs assessing conservative management of CR. Information extracted was analyzed to determine the level of homogeneity and/or heterogeneity of the inclusion and exclusion criteria across studies. RESULTS: Seventy-six RCTs met our inclusion criteria with 68 distinct trials identified. The inclusion of arm pain with or without another symptom ( i.e. numbness, paresthesia, or weakness) was required in 69.12% of trials, 50% of trials required participants to exhibit neck symptoms, and 73.53% of studies required some form of clinical examination findings, but inconsistencies existed for the number and type of tests used. Furthermore, 41.18% of trials included imaging, with 33.82% of trials requiring magnetic resonance imaging findings. The most common exclusion criteria included were the presence of red flags and cervical myelopathy in 66.18% and 58.82% of trials, respectively. CONCLUSIONS: Overall, there is still a lack of uniformity for the inclusion/exclusion criteria of trials assessing the conservative management of CR, with some improvements noted compared with the 2012 review. Based on the current literature assessing the diagnostic utility of clinical symptoms and confirmatory tests, we proposed inclusion criteria for trials assessing conservative interventions. Future research should aim to develop standardized classification criteria to improve consistency among studies.

Conservative Management of Cervical Radiculopathy: A Systematic Review.

OBJECTIVE: The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR). METHODS: We searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022 to identify studies that were randomized controlled trials, had at least one conservative treatment arm, and diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests. Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach. RESULTS: Of the 2561 records identified, 59 trials met our inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively. There is very-low certainty evidence supporting the use of acupuncture, prednisolone, cervical manipulation, and low-level laser therapy for pain and disability in the immediate to short-term, and thoracic manipulation and low-level laser therapy for improvements in cervical range of motion in the immediate term. There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion. There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty. DISCUSSION: There is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.

Intra- and inter-rater reliability of an electronic health record audit used in a chiropractic teaching clinic system: an observational study.

BACKGROUND: There is a dearth of information about health education clinical file audits in the context of completeness of records and demonstrating program-wide competency achievement. We report on the reliability of an audit instrument used for electronic health record (EHR) audits in the clinics of a chiropractic college in Canada. METHODS: The instrument is a checklist built within an electronic software application designed to pull data automatically from the EHR. It consists of a combination of 61 objective (n = 20) and subjective (n = 41) elements, representing domains of standards of practice, accreditation and in-house educational standards. Trained auditors provide responses to the elements and the software yields scores indicating the quality of clinical record per file. A convenience sample of 24 files, drawn randomly from the roster of 22 clinicians, were divided into three groups of eight to be completed by one of three auditors in the span of 1 week, at the end of which they were transferred to another auditor. There were four audit cycles; audits from cycles 1 and 4 were used to assess intra-rater (test-retest) reliability and audits from cycles 1, 2 and 3 were used to assess inter-rater reliability. Percent agreement (PA) and Kappa statistics (K) were used as outcomes. Scatter plots and intraclass correlation (ICC) coefficients were used to assess standards of practice, accreditation, and overall audit scores. RESULTS: Across all 3 auditors test-retest reliability for objective items was PA 89% and K 0.75, and for subjective items PA 82% and K 0.63. In contrast, inter-rater reliability was moderate at PA 82% and K 0.59, and PA 70% and K 0.44 for objective and subjective items, respectively. Element analysis indicated a wide range of PA and K values inter-rater reliability of many elements being rated as poor. ICC coefficient calculations indicated moderate reliability for the domains of standards of practice, accreditation, and overall file scores. CONCLUSION: The file audit process has substantial test-retest reliability and moderate inter-rater reliability. Recommendations are made to improve reliability outcomes. These include modifying the audit checklist with a view of improving clarity of elements, and enhancing uniformity of auditor responses by increased training aided by preparation of an audit guidebook.

A case report on the delayed diagnosis of transverse myelitis in a 61-year-old male farmer.

Transverse myelitis is a neurological disorder that results in acute focal inflammation of the spinal cord. It can present with a varied spectrum of neurological signs and symptoms which can make diagnosing a challenge, and delayed diagnosis a frequent complication. This is a case of a 61-year-old male who presented with back pain complicated by neurological symptoms that should have warranted immediate referral to a neurologist. It took approximately five weeks from the onset of his symptoms to be referred to a neurologist, and a further four months to the diagnosis of transverse myelitis. The authors hope to stress the importance of thorough evaluations including neurological exams when new symptoms present and to emphasize regular interprofessional collaboration, that may have prevented the delay in diagnosis seen in this case.

La myélite transverse est un trouble neurologique se manifestant par une inflammation focale aiguë de la moelle épinière. Le sujet peut présenter divers signes et symptômes neurologiques qui peuvent rendre le diagnostic difficile. Un diagnostic tardif entraîne de fréquentes complications. Il s'agit d'un homme de 61 ans ayant des dorsalgies et des symptômes neurologiques qui auraient dû justifier son renvoi immédiat à un neurologue. Environ cinq semaines après l'apparition des symptômes se sont écoulées avant le renvoi à un neurologue, et par la suite quatre mois se sont écoulés avant qu'un diagnostic de myélite transverse ne soit établi. Les auteurs de l'étude espèrent souligner l'importance des évaluations poussées, y compris des examens neurologiques lorsque de nouveaux symptômes apparaissent, et l'importance d'une collaboration régulière entre professions, ce qui aurait permis d'éviter le retard de diagnostic dans le cas de ce patient.

Pathological burst fracture in the cervical spine with negative red flags: a 12-year follow-up.

In 2004, a 61-year-old male presented to a chiropractic clinic complaining of neck pain after hearing a 'crunch' when getting out of bed that morning. The initial history intake and physical examination identified no red flags or indications for the patient's pain, with the exception of traction being pain-provoking. Conventional radiographs were ordered, which identified a pathological burst fracture of the fourth cervical vertebra. This Imaging Case Review (ICR) is to provide clinicians with a follow-up to the patient's care and current state.

En 2004, un homme de 61 ans se présente à une clinique de chiropratique en se plaignant de douleur cervicale après avoir entendu un craquement en se levant du lit le matin même. Au début, les antécédents et l'examen physique n'ont pas permis de déceler de signal d'alerte ou d'indication expliquant la douleur du patient, sauf pour la traction qui provoquait de la douleur. On a procédé à des radiographies traditionnelles qui ont décelé une fracture-éclatement pathologique de la quatrième vertèbre cervicale. Cet examen de cas d'imagerie a pour but de fournir aux cliniciens un suivi des soins prodigués au patient et de son état actuel.

Impact of providing case-specific knowledge in simulation: a theory based study of learning.

Background: Simulation-based education (SBE) has been lauded for its ability to help students recognise and react appropriately to common and rare circumstances. While healthcare professions have started to implement SBE into their curriculum, there is no evidence to suggest which educational theory is best for implementation. This study explores the usage of cognitive load theory (CLT) and the unified theory of emotional learning (UTEL). Study design: A mixed methods ordered-allocation cohort study. Methods: 23 patient management teams were allocated into 2 groups. The first group received prior information about the simulation scenario; the second group did not. Each team had 1 student assigned to the role of doctor. The scenarios were filmed at time 1 (T1), time 2 (T2) and follow-up (F/U). The 'doctor' role was then graded with a validated checklist by a three-judge panel. The scores were evaluated to determine if prior information enabled better performance. Secondary analysis evaluated the role of gender on performance and also evaluated anxiety at the onset of the simulation. Results: 23 doctors were evaluated. There was no difference between groups in performance (t=1.54, p=0.13). Secondary analysis indicated that gender did not play a role. There was no difference in anxiety between groups at baseline (t=0.67, p=0.51). Conclusions: Trends were observed, suggesting that when students enter a simulation environment with prior knowledge of the event they will encounter, their performance may be higher. No differences were observed in performance at T2 or F/U. Withholding information appeared to be an inappropriate proxy for emotional learning as no difference in anxiety was observed between groups at baseline. All trends require confirmation with a larger sample size.

The biomechanical demands of manual scaling on the shoulders & neck of dental hygienists.

The purpose of this study was to evaluate the postural and muscular demands placed on the shoulders and neck of dental hygienists when performing a simulated manual scaling task. Nineteen healthy female dental hygienists performed 30-min of simulated manual scaling on a manikin head in a laboratory setting. Surface electromyography was used to monitor muscle activity from several neck and shoulder muscles, and neck and arm elevation kinematics were evaluated using motion capture. The simulated scaling task resulted in a large range of neck and arm elevation angles and excessive low-level muscular demands in the neck extensor and scapular stabilising muscles. The physical demands varied depending on the working position of the hygienists relative to the manikin head. These findings are valuable in guiding future ergonomics interventions aimed at reducing the physical exposures of dental hygiene work. Practitioner Summary: Given that this study evaluates the physical demands of manual scaling, a procedure that is fundamental to dental hygiene work, the findings are valuable to identify ergonomics interventions to reduce the prevalence of work-related injuries, disability and the potential for early retirement among this occupational group.

Neck pain in children: a retrospective case series.

INTRODUCTION: Spinal pain in the paediatric population is a significant health issue, with an increasing prevalence as they age. Paediatric patients attend for chiropractor care for spinal pain, yet, there is a paucity of quality evidence to guide the practitioner with respect to appropriate care planning. METHODS: A retrospective chart review was used to describe chiropractic management of paediatric neck pain. Two researchers abstracted data from 50 clinical files that met inclusion criteria from a general practice chiropractic office in the Greater Toronto Area, Canada. Data were entered into SPSS 15 and descriptively analyzed. RESULTS: Fifty paediatric neck pain patient files were analysed. Patients' age ranged between 6 and 18 years (mean 13 years). Most (98%) were diagnosed with Grade I-II mechanical neck pain. Treatment frequency averaged 5 visits over 19 days; with spinal manipulative therapy used in 96% of patients. Significant improvement was recorded in 96% of the files. No adverse events were documented. CONCLUSION: Paediatric mechanical neck pain appears to be successfully managed by chiropractic care. Spinal manipulative therapy appears to benefit paediatric mechanical neck pain resulting from day-today activities with no reported serious adverse events. Results can be used to inform clinical trials assessing effectiveness of manual therapy in managing paediatric mechanical neck pain.

INTRODUCTION: La douleur vertébrale chez la population pédiatrique constitue un important problème desanté, avec une prévalence croissante à mesure qu'ils grandissent. Les patients pédiatriques consultent des chiropraticiens pour des douleurs vertébrales; toutefois, il y a toujours un manque de preuves de qualité pour guider le praticien à planifier des soins appropriés. MÉTHODOLOGIE: Un examen rétrospectif des dossiers a été utilisé pour décrire la gestion chiropratique dela douleur cervicale chez les patients pédiatriques. Deux chercheurs ont extrait des données d'une clinique de chiropratique de la région du Grand Toronto, au Canada, portant sur 50 dossiers cliniques qui répondaient aux critères d'inclusion. Les données ont été saisies dans SPSS 15 et soumises à une analyse descriptive. RÉSULTATS: Cinquante dossiers de patients pédiatriques souffrant de douleurs cervicales ont été analysés. La tranche d'âge des patients variait de 6 à 18 ans (moyenne de 13 ans). La plupart (98 %) ont reçu un diagnostic de cervicalgie mécanique de stade I­II. La fréquence de traitement était en moyenne 5 visites sur une période de 19 jours, la thérapie de manipulation vertébrale étant utilisée pour 96 % des patients. Une amélioration significative a été enregistrée dans 96 % des cas. Aucun incident indésirable n'a été documenté. CONCLUSION: Il semble que la cervicalgie mécanique chez les patients en pédiatrie soit gérée avec succès par des soins chiropratiques. La thérapie de manipulation vertébrale semble être bénéfique au traitement, chez les patients pédiatriques, de la cervicalgie mécanique survenue à la suite des activités quotidiennes sans signalement d'effets indésirables graves. Les résultats peuvent être utilisés pour informer les essais cliniques évaluant l'efficacité de la thérapie manuelle dans la gestion de la cervicalgie mécanique chez les patients en pédiatrie.

Pathological burst fracture in the cervical spine with negative red flags: a case report.

OBJECTIVE: To report on a case of a pathological burst fracture in the cervical spine where typical core red flag tests failed to identify a significant lesion, and to remind chiropractors to be vigilant in the recognition of subtle signs and symptoms of disease processes. CLINICAL FEATURES: A 61-year-old man presented to a chiropractic clinic with neck pain that began earlier that morning. After a physical exam that was relatively unremarkable, imaging identified a burst fracture in the cervical spine. INTERVENTION & OUTCOMES: The patient was sent by ambulance to the hospital where he was diagnosed with multiple myeloma. No medical intervention was performed on the fracture. SUMMARY: The patient's initial physical examination was largely unremarkable, with an absence of clinical red flags. The screening tools were non-diagnostic. Pain with traction and the sudden onset of symptoms prompted further investigation with plain film imaging of the cervical spine. This identified a pathological burst fracture in the C4 vertebrae.

OBJECTIF: Présenter un cas de fracture-éclatement pathologique dans la colonne cervicale où les tests de base pour révéler des signes alarmants n'ont pas réussi à identifier une lésion significative, et rappeler les chiropraticiens à être vigilants dans la reconnaissance des signes et symptômes subtils des processus pathologiques. CARACTÉRISTIQUES CLINIQUES: Un homme âgé de 61 ans s'est présenté à une clinique de chiropratique avec une douleur cervicale qui a commencé tôt le matin. Après un examen physique relativement banal, l'imagerie a révélé une fracture-éclatement du rachis cervical. INTERVENTION ET RÉSULTATS: L'ambulance a transporté le patient à l'hôpital où il a reçu un diagnostic de myélome multiple. Aucune intervention médicale n'a été effectuée sur la fracture. RÉSUMÉ: L'examen physique initial du patient était banal et sans signes alarmants cliniques. Les outils de dépistage n'ont pas pu diagnostiquer. La douleur avec la traction et l'apparition soudaine de symptômes ont incité un examen plus approfondi avec l'imagerie par radiographie du rachis cervical. Cela a révélé une fracture-éclatement pathologique dans la vertèbre C4.

Effectiveness of Acupuncture Therapies to Manage Musculoskeletal Disorders of the Extremities: A Systematic Review.

Study Design Systematic review. Background Little is known about the effectiveness of acupuncture therapies for musculoskeletal disorders. Objective To assess the effectiveness and safety of acupuncture therapies for musculoskeletal disorders of the extremities. Methods We searched MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from 1990 to 2015 for randomized controlled trials, cohort studies, and case-control studies. Eligible studies were appraised with Scottish Intercollegiate Guidelines Network criteria. A best-evidence synthesis was performed to synthesize results from included studies with a low risk of bias. A sensitivity analysis was conducted to determine the impact of excluding studies with a high risk of bias. Results The search revealed 5180 articles; 15 were included (10 with a low risk of bias, 5 with a high risk of bias). The studies with a low risk of bias suggested that (1) traditional needle acupuncture was superior to oral steroids (1 RCT, n = 77) and may be superior to vitamin B1/B6 supplements (1 RCT, n = 64) for carpal tunnel syndrome (CTS), and was superior to exercise for Achilles tendinopathy (1 RCT, n = 64). Traditional needle acupuncture did not provide important benefit over placebo for upper extremity pain (1 RCT, n = 128), or no intervention for patellofemoral pain (1 RCT, n = 75), and was inconclusive for shoulder pain (2 RCTs, n = 849), suggesting no important benefit; (2) electroacupuncture may be superior to placebo for shoulder injuries (1 RCT, n = 130) and may not be superior to night splinting for persistent CTS (1 RCT, n = 78); and (3) dry needling may be superior to placebo for plantar fasciitis (1 RCT, n = 84). Sensitivity analysis suggests that including studies with a high risk of bias might have impacted the evidence synthesis in support of managing shoulder pain with traditional needle acupuncture, and that would suggest traditional needle acupuncture may be effective for lateral epicondylitis and piriformis syndrome. Conclusion Evidence for the effectiveness of acupuncture for musculoskeletal disorders of the extremities was inconsistent. Traditional needle acupuncture may be beneficial for CTS and Achilles tendinopathy, but not for nonspecific upper extremity pain and patellofemoral syndrome. Electroacupuncture may be effective for shoulder injuries and may show similar effectiveness to that of night wrist splinting for CTS. The effectiveness of dry needling for plantar fasciitis is equivocal. Level of Evidence Therapy, 1a-. J Orthop Sports Phys Ther 2016;46(6):409-429. Epub 26 Apr 2016. doi:10.2519/jospt.2016.6270.

The Effectiveness of Exercise on Recovery and Clinical Outcomes in Patients With Soft Tissue Injuries of the Hip, Thigh, or Knee: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: The purpose of this systematic review was to determine the effectiveness of exercise for the management of soft tissue injuries of the hip, thigh, and knee. METHODS: We conducted a systematic review and searched MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL Plus with Full Text from January 1, 1990, to April 8, 2015, for randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effect of exercise on pain intensity, self-rated recovery, functional recovery, health-related quality of life, psychological outcomes, and adverse events. Random pairs of independent reviewers screened titles and abstracts and assessed risk of bias using the Scottish Intercollegiate Guidelines Network criteria. Best evidence synthesis methodology was used. RESULTS: We screened 9494 citations. Eight RCTs were critically appraised, and 3 had low risk of bias and were included in our synthesis. One RCT found statistically significant improvements in pain and function favoring clinic-based progressive combined exercises over a "wait and see" approach for patellofemoral pain syndrome. A second RCT suggests that supervised closed kinetic chain exercises may lead to greater symptom improvement than open chain exercises for patellofemoral pain syndrome. One RCT suggests that clinic-based group exercises may be more effective than multimodal physiotherapy in male athletes with persistent groin pain. CONCLUSION: We found limited high-quality evidence to support the use of exercise for the management of soft tissue injuries of the lower extremity. The evidence suggests that clinic-based exercise programs may benefit patients with patellofemoral pain syndrome and persistent groin pain. Further high-quality research is needed.

Working position influences the biomechanical demands on the lower back during dental hygiene.

This investigation monitored the biomechanical demands on the lower back during simulated dental hygiene work. A total of 19 female, registered dental hygienists performed 30 continuous minutes of manual scaling (plaque removal) of a manikin's teeth while seated. We monitored the working location and orientation of the dental hygienists, with respect to the manikin, along with their spine kinematics, spine extensor muscle activities and seat pressure, throughout the 30 min. A clock representation was used to express the working location. The location significantly influenced the dental hygienists' pelvic orientation with respect to the manikin, spine posture, erector muscle activity and pressure distribution. Findings from this study suggest that the prevalence of lower back pain amongst dental hygienists may be directly related to low-level tonic activity of the spine's extensor musculature, and the combined flexed and axially rotated spine postures. Practitioner Summary: Low back pain (LBP) is prevalent in dental hygienists, yet occupational demand on the low back has not been investigated. Posture, muscle activity and seat pressure were monitored. Combined spine rotation and flexion, and tonic activity of the extensor musculature may be related to LBP in dental hygienists.

Missed appendicitis diagnosis: A case report.

OBJECTIVE: The purpose of this case report is to highlight and emphasize the need for an appropriate and thorough list of differential diagnoses when managing patients, as it is insufficient to assume cases are mechanical, until proven non-mechanical. There are over 250,000 cases of appendicitis annually in the United States. Of these cases, <50% present with classic signs and symptoms of pain in the right lower quadrant, mild fever and nausea. It is standard for patients who present with appendicitis to be managed operatively with a laparoscopic appendectomy within 24 hours, otherwise the risk of complications such as rupture, infection, and even death increases dramatically. CLINICAL FEATURES: This is a retrospective case report following a 27-year-old male with missed appendicitis, who presented to a chiropractor two-weeks after self-diagnosed food poisoning. On assessment, he was tender with resisted lumbar rotation. Psoas Sign, McBurney's Point, vascular exam, hip exam, were negative. A diagnosis of an abdominal strain was provided. Two weeks later, he returned to the chiropractor without an improvement of symptoms. INTERVENTION & OUTCOME: The patient was sent to the hospital, where he was provided a diagnosis of missed appendicitis. He required a hemicolonectomy due to the associated phlegmonous mass. SUMMARY: When a patient presents to a chiropractic clinic with symptoms of abdominal pain, having a comprehensive list of non-mechanical differential diagnoses as well as mechanical differentials is crucial. Appropriate assessment and management of abdominal cases decreases the risk to patients, as missed diagnoses often require more invasive interventions.

OBJECTIF: Cette étude de cas vise à souligner la nécessité d'une liste appropriée et détaillée de diagnostics différentiels lors de la gestion des patients, car il n'est pas suffisant de supposer que les cas sont d'ordre mécanique, jusqu'à la preuve du contraire. Il y a plus de 250 000 cas d'appendicite par an aux États-Unis. Parmi ces cas, < 50 % présentent des signes et des symptômes classiques de douleur dans le quadrant inférieur droit, de fièvre légère et de nausées. Il est normal qu'un patient qui se présente avec une appendicite soit géré par une intervention chirurgicale (appendicectomie par laparoscopie) dans les 24 heures, sinon le risque de complications, telles que rupture, infection et décès, augmente considérablement. CARACTÉRISTIQUES CLINIQUES: Ceci est une étude de cas rétrospective qui suit un homme de 27 ans dont le diagnostic d'appendicite a été manqué lorsqu'il s'est présenté à un chiropraticien deux semaines après un autodiagnostic d'intoxication alimentaire. Son examen avait révélé une sensibilité au toucher avec une résistance à la rotation lombaire. Le signe du psoas, le point de McBurney, l'examen vasculaire et l'examen de la hanche se sont révélés négatifs. Un diagnostic de claquage abdominal a été établi. Deux semaines plus tard, il est retourné au chiropraticien sans aucune amélioration des symptômes. INTERVENTION ET RÉSULTATS: Le patient a été envoyé à l'hôpital, où une appendicite manquée a été diagnostiquée. Il a fallu lui faire une hémicolectomie en raison de la masse phlegmoneuse associée. RÉSUMÉ: Quand un patient se présente à une clinique de chiropratique avec des symptômes de douleurs abdominales, il est crucial d'avoir une liste complète de diagnostics différentiels non-mécaniques ainsi que de différentiels mécaniques. L'évaluation et la gestion appropriées des douleurs abdominales diminuent le risque pour les patients, car les diagnostics manqués nécessitent souvent des interventions plus invasives.

The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

BACKGROUND: Musculoskeletal disorders (MSDs) of the upper and lower extremities are common in the general population and place a significant burden on the health care system. Manual therapy is recommended by clinical practice guidelines for the management of these injuries; however, there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of manual therapy in adults or children with MSDs of the upper or lower extremity. METHODS: Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of manual therapy were eligible. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best-evidence synthesis principles. Where available, we computed mean changes between groups, relative risks and 95 % CI. RESULTS: We screened 6047 articles. Seven RCTs were critically appraised and three had low risk of bias. For adults with nonspecific shoulder pain of variable duration, cervicothoracic spinal manipulation and mobilization in addition to usual care may improve self-perceived recovery compared to usual care alone. For adults with subacromial impingement syndrome of variable duration, neck mobilization in addition to a multimodal shoulder program of care provides no added benefit. Finally, for adults with grade I-II ankle sprains of variable duration, lower extremity mobilization in addition to home exercise and advice provides greater short-term improvements in activities and function over home exercise and advice alone. No studies were included that evaluated the effectiveness of manual therapy in children or for the management of other extremity injuries in adults. CONCLUSIONS: The current evidence on the effectiveness of manual therapy for MSDs of the upper and lower extremities is limited. The available evidence supports the use of manual therapy for non-specific shoulder pain and ankle sprains, but not for subacromial impingement syndrome in adults. Future research is needed to determine the effectiveness of manual therapy and guide clinical practice. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42014009899.

The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of exercise compared to other interventions, placebo/sham intervention, or no intervention in improving self-rated recovery, functional recovery, clinical, and/or administrative outcomes in individuals with musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand. METHODS: We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers independently screened studies for relevance and assessed the risk of bias using the Scottish Intercollegiate Guidelines Network criteria. We synthesized the evidence using the best evidence synthesis methodology. RESULTS: We identified 5 studies with a low risk of bias. Our review suggests that, for patients with persistent lateral epicondylitis, (1) adding concentric or eccentric strengthening exercises to home stretching exercises provides no additional benefits; (2) a home program of either eccentric or concentric strengthening exercises leads to similar outcomes; (3) home wrist extensor strengthening exercises lead to greater short-term improvements in pain reduction compared to "wait and see"; and (4) clinic-based, supervised exercise may be more beneficial than home exercises with minimal improvements in pain and function. For hand pain of variable duration, supervised progressive strength training added to advice to continue normal physical activity provides no additional benefits. CONCLUSION: The relative effectiveness of stretching vs strengthening for the wrist extensors remains unknown for the management of persistent lateral epicondylitis. The current evidence shows that the addition of supervised progressive strength training does not provide further benefits over advice to continue normal physical activity for hand pain of variable duration.

Onsite QTc interval screening for patients in methadone maintenance treatment.

To improve the electrocardiogram screening process and early detection of patients at high risk for cardiac arrhythmias, the authors created a model in their clinic where they provided an onsite electrocardiogram screening that might be feasible and practical. The authors then performed a retrospective chart review to access the efficacy and feasibility of their new onsite procedure in identifying methadone maintained patients at high risk for cardiac arrhythmias. Records from all patients who are currently or had previously been maintained on methadone in the methadone maintenance program at the Atlanta VA Medical Center between 2002 and 2009 were evaluated. Of the 140 patients treated at the clinic between 2002 and 2009, 85 were excluded from the study because they had been treated as guests (had been in treatment in other clinics but received methadone dosing temporarily from our clinic), were treated in the clinic for less than 6 months, or dropped out of treatment. Thus, 55 patient charts were selected for review. Most patients (95%) received baseline and annual electrocardiogram screening. The average baseline QTc was (417 +/- 30) and most recent QTc (442 +/- 25). This QTc prolongation from baseline showed statistical significance (P < .0001). Sixty-seven percent of patients had statistically significant QTc prolongation from baseline but was less than 450 ms (mean: 428 +/- 16, P = .008). Twenty-seven percent of patients had statistically significant QTc prolongation from baseline of more 450 ms but was less than 500 ms (mean: 460 +/- 8, P < .0001). Six percent of patients had statistically significant QTc prolongation from baseline of more 500 ms (mean: 503 +/- 1.15, P = .027). Recent cocaine use was the only individual variable that showed statistically significant correlation with QTc prolongation (F = 6.98, P = .01). The authors demonstrated in this study that providing an onsite electrocardiogram screening with a focus on patient education and limiting the referral to specialty care for patients at high risk for cardiac arrhythmias could be practical and feasible.